BHIPP Bulletin
Volume 7, Issue 8
February 2022
Supporting Healthy Eating
Habits in Childhood
This month's BHIPP Bulletin is a contribution from Carisa Parrish, PhD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine, Director of Pediatric Health Psychology, Johns Hopkins Children's Center and BHIPP Consultant.
How much did your baby weigh at birth? How is he eating? Have you started weaning to solid foods yet? Is your toddler gaining enough weight? Parental monitoring of children’s eating habits begins early in development. Although much public health concern focuses on children struggling with obesity, children’s eating habits can be a source of concern for parents across the weight continuum. Our BHIPP Resilience Break for February focuses on picky eating in young children. Below we will briefly review evidence-based strategies for supporting parents in improving healthy eating habits, as well as reducing selective eating behaviors.
In 2013, avoidant/restrictive food intake disorder (ARFID) was added to the psychiatric nomenclature as part of the DSM-5. ARFID was an extension of childhood feeding disorders and is conceptualized with key features of food avoidance or restriction; sensitivity to sensory qualities of food (e.g., texture); lack of interest in eating; and fear of negative consequences of eating. The lack of focus on avoiding weight gain or attention to body image distinguishes ARFID from other eating disorders, as well as the equal prevalence of this problem among boys and girls. Unfortunately, persistent picky eating that affects age-appropriate weight gain or growth curve, results in dependence on dietary supplementation, leads to nutritional deficiencies, and interferes with psychosocial functioning meets criteria for ARFID and indicates need for further assessment and treatment. Prevalence estimates range from <1% to 3% in school-age samples. By contrast, the less severe manifestations of picky eating are much more common, with estimates of 13-30% during early childhood. The more common presentation of picky eating may provide an opportunity for primary care providers to intervene before the problem becomes more entrenched.
Ways to improve healthy eating
There are several behavioral strategies that may be useful for improving children’s healthy eating habits, whether you have a currently picky eater or simply wanting to practice good habits.
  • Establish mealtime routines, with good spacing from snack time. Routine could incorporate expectation that children taste new foods regularly, with multiple opportunities over time to taste new foods.

  • Eat together as a family. Parents are encouraged to keep mealtime pleasant and avoid struggles.

  • Positive eating role models: Parents and siblings can model desired behavior during mealtimes (e.g., trying new foods, eating without TV/tablet, sitting at table with family until completion of meal together).

  • Rewards for positive eating behaviors, such as trying new foods, to encourage bravery and curiosity. As with rewards generally, the reward will only work if it is meaningful and interesting to the child.

  • Decrease attention to negative behaviors associated with eating, such as food refusal tantrums, whining, complaining about non-preferred foods. This strategy would also involve prevention of escape behaviors associated with avoiding non-preferred foods.

  • Limit junk food and sweet drinks. Frequent access to junk foods and fast food may interfere with parental promotion of healthy alternatives. Reduce this competition by providing readily available healthy snacks. Encourage your child to drink water when thirsty.

  • Exposure therapy: It may be helpful to have a structured approach to decreasing a child’s avoidance to specific foods through repeated exposures. Exposure therapy can start at a low intensity (e.g., one bite of non-preferred food on plate) to prevent excessive avoidance and anxiety.

What if a child’s picky eating meets criteria for ARFID?
The ARFID diagnosis is relatively new to the DSM-5, so preliminary studies are still beginning to evaluate potentially effective treatments for this condition. There are three treatments that are showing positive preliminary results: (1) cognitive-behavioral therapy adapted for ARFID, (2) family-based treatment previously developed for youth with anorexia, and (3) family-based, cognitive-behavioral treatment previously used with children with anxiety disorders as part of the Unified Protocol by psychologists David Barlow and colleagues. These treatments are all based on cognitive-behavioral approaches to treatment that have a heavy emphasis on re-establishing the family context of family meals. For younger children and youth with autism spectrum disorders, applied behavioral analytic approaches may be most appropriate. Multidisciplinary care is typically recommended in the case of ARFID, as with other eating/feeding disorders. Treatment team may involve medical care, nutrition counseling, speech-language therapy, behavioral psychology, and child psychiatry. Further, because many children with ARFID have additional psychiatric conditions (e.g., autism spectrum disorder, anxiety disorder, ADHD, obsessive-compulsive disorder, behavioral difficulties), multidisciplinary consultation is encouraged to ensure adequate assessment of co-occurring conditions that may warrant additional treatments. 
As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 
855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.

We will keep you informed about all our services and training events through our website ( and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, Twitter, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.
Specialized feeding programs in Maryland

Further Reading

BHIPP Announcements
BHIPP in Your Neighborhood
  • February 26-27, 2022
  • Maryland Academy of Family Physicians Annual Meeting
  • Stop by our exhibit booth!
  • March 1, 2022 12:30-1:30pm
  • BHIPP Crisis: Your next patient has Autism: Are you prepared? presented by Trish Kane, Deputy Director, Pathfinders for Autism
  • Register here!
  • March 13, 2022 12:30-1:30pm
  • BHIPP Resilience Break: Culturally Responsive, Trauma-Informed Practices for Pediatric Primary Care and Behavioral Health Providers presented by Tiffany Beason, PhD
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BHIPP is supported by funding from the Maryland Department of Health, Behavioral Health Administration and operates as a collaboration between the University of Maryland School of Medicine, the Johns Hopkins University School of Medicine, Salisbury University and Morgan State University.

BHIPP and this newsletter are also supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $433,296 with approximately 20% financed by non-governmental sources. The contents of this newsletter are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government. For more information, visit

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